Knowledgebase-HIPAA Training Acknowledgment Form


Information Product

Title:HIPAA Training Acknowledgment Form
Summary:A form to acknowledge the receipt of a copy of the Town's HIPAA policy and training on that policy.
Original Author:Norris, Margaret
Co-Author:
Product Create Date:08/27/2003
Last Reviewed on::05/16/2017
Subject:Forms; Insurance--Health; Insurance; Records management--Open records; Records management--Open records--Laws and regulations; Personnel--Fringe benefits--Laws and regulations; Personnel--Fringe benefits; Personnel--Laws and regulations--Federal
Type:Form
Original Document: HIPAA training acknowledgment form.pdfHIPAA training acknowledgment form.pdf

Reference Documents:

Text of Document: HIPAA training acknowledgment form.docHIPAA training acknowledgment form.doc


HIPAA TRAINING ACKNOWLEDGMENT FORM
Town of ___________



As an employee, I hereby acknowledge that I have received and do now possess a complete and current copy of the Town of Centerville’s Health Insurance Portability and Accountability Act (HIPAA) Policy passed by resolution on ___________, 20__. I also acknowledge that I received and participated in training on this policy on ____________, 20__.

I agree without reservation to follow and abide by the policies, procedures, rules and regulations contained therein.

Furthermore, I understand that the Town reserves the right to change any of such rules, regulations, policies, practices, and procedures in whole or in part at any time, with or without notice to employees.






Name of Employee: _____________________________________________________________



Department Name: ______________________________________________________________



Social Security Number: _________________________________________________________






Signature of Employee ___________________________________ Date______________



Signature of Witness _____________________________________ Date______________